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Falls are a major cause of disability, are the leading cause of mortality resulting from injury, and have a huge impact on health-care costs. 33€“50% of people older than 65 years fall each year. Thousands of those fall at home, and more than 1000 die after falling down stairs.¹ Falls account for more than 80% of all injury-related admissions to hospital in that age group. The cost to the NHS and Social Services is £981 million, and £600 million of that is for the over 75s.

The myelodysplastic syndromes are a group of disorders predominantly affecting elderly people, leading to ineffective haematopoiesis, and they have the potential to develop into leukaemia. Classification and prognostic systems help to divide patients with widely varying diseases into categories with a similar clinical course.

Within chronic pain states, neuropathic pain is often poorly recognised, yet its presence worsens prognosis and complicates treatment. Although it often exists in isolation after damage to nerves, more commonly it occurs alongside inflammatory pain.

The reciprocal link between depression and poor physical health has long been recognised. Exercise is a useful intervention, and its direct benefits may be enhanced by the increased social engagement elicited. A healthy diet is probably helpful, but no specific nutritional deficiencies have been conclusively linked with depression. Religious and spiritual activities seem beneficial, in part due to social functioning. Loneliness and isolation are associated with both development of and maintenance of depression.

Specialist stroke rehabilitation aims to promote independence and reintegration into the community. Early supported discharge of stroke patients with mild-to-moderate disability by a coordinated multidisciplinary team not only improves physical functioning, but also reduces the economic burden of post-stroke care.

Generalised anxiety disorder is common and can present in older people, often in conjunction with depressive symptoms. Pharmacological treatments have included tricyclic antidepressants, benzodiazepines, and antipsychotics, but a selection of new drugs are now specifically licensed for this disorder. Psychological therapies such as cognitive behaviour therapy and changing lifestyle factors, such as substance misuse and exercise are also important to achieve therapeutic success. 

Low back pain is a common presenting symptom in older patients and results in significant disability and functional decline. We look at the important causes of low back pain, the imaging techniques to diagnose the underlying pathology, and management options.

Gallstone disease and its complications are extremely common in elderly populations; therefore in the context of the UK's ageing population and recent advances in biliary tract surgery, this review outlines the key aspects of managing gallstone disease.

Dementia with Lewy bodies is a common form of dementia that remains underdiagnosed and poorly understood by most health-care professionals. The general practitioner will often mbe the first doctor that patients or their concerned relatives see. A few fairly simple signs and symptoms should raise suspicions of the diagnosis. The general practitioner can offer invaluable support and information to the patient and their family, including advanced care planning. Drug treatment for this disease is limited, although useful in selected cases. A large amount of research is being conducted into this form of dementia that will hopefully lead to improved treatments.

The psychostimulants methylphenidate and dexamfetamine have been used safely in child psychiatry for attention deficit and hyperactivity disorder for more than two decades. Use of stimulants in elderly people probably predates that in children; however, interest was not sustained, and little progress has been made.

One thing about being a doctor, whether in general practice or in hospital, that never gets easier, is telling a patient that their test results are not good€”and then fielding the inevitable €œHow long have I got?€ Once the patient has begun to absorb the bad news, or perhaps even in expectation of bad news, most patients want to deal with all sorts of practical questions, from updating their will, to what they want played at the funeral. Many doctors will therefore welcome, as I did, the website Lasting Post. It is a free resource to point patients to information that can be of real help. It also aims to help those left behind, in both practical and supportive ways. When I saw this website, I was so impressed that I became its medical adviser.

Venous thromboembolism is a major cause of morbidity and mortality in hospital, and elderly patients are at particularly high risk. Trials consistently show the efficacy of prophylactic low molecular-weight heparin in reducing thromboses. A previous audit in our Trust showed that only 36% of high-risk patients received appropriate thromboprophylaxis, and, as a result, a new hospital protocol was developed. Our subsequent audit a year later showed a substantial improvement, with 75% patients receiving appropriate thromboprophylaxis.

Older patients can benefit greatly from elective surgery, but complications and adverse events must be considered. Variables that affect outcome include the differing risks of particular procedures and the functional capacity and comorbidities of the patient. Many people can undergo surgery successfully if their conditions are managed appropriately before, during, and after surgery.

Carotid endarterectomy is a surgical procedure in which an atherosclerotic plaque is removed from the carotid artery to avoid future stroke. A small proportion of patients will have adverse effects from surgery and need emergency blood-pressure management to avoid intracranial haemorrhage. This paradoxical risk of operation-related stroke leads to continuing controversy about this procedure. Data for carotid endarterectomy in asymptomatic patients are less conclusive than those for symptomatic patients. Trials are underway to determine the benefits of carotid angioplasty with stenting.

Falls and related fractures are a major cause of disability and mortality in older people. Falls prevention services have been available in the UK for many years, but audits of these services show that improvements are needed. We discuss the results of the most recent audit, published in March 2009.